Sharing personal lessons on sporting injuries

Author: theinjurypronetriathlete

Hopefully the statement above triggered the same ‘WTF?!’ response as it did with me when I first heard it. I’m not a medical expert but could this additional set of lungs be the human body’s best kept secret? It would seem unlikely.

As almost a complete yoga novice, having only been to about 5 classes and followed some online videos, perhaps the most unexpected challenge has been getting to grips with the slightly abstract terminology. However, it’s starting to become clear that in many ways this is actually quite a necessity. Being based entirely upon personal perception, the feeling of ‘breathing through your hips’ of course has no absolute definition. In fact, it is concerned with relaxing the soft tissue surrounding the hips by controlling your breathing and focusing the mind.

The hips are fundamentally important to every discipline of triathlon. One of the greatest revelations a novice swimmer experiences is the effect that kicking from the hips rather than the knees can have upon freestyle swim speed. By transferring the primary contracting muscles further up the body, drag can be greatly reduced, rotation can be better controlled and a level position in the water can be maintained. In cycling, one of the greatest confining factors concerned with finding the most aerodynamic yet powerful position is hip mobility. In running, the gluteal muscles play a greater role in locomotion than any other. Although, in todays deskbound society these large muscles can become lazy and disengaged, placing undue stress on other leg muscles and making it hard to hold form while running.

So, where am I going with this?

‘Train intentionally, not habitually’ – Naudi Aguilar

Reading this phrase, the motto of Functional Patterns, struck a chord. Whether heading out on the bike or popping squats in the gym it’s all too easy to mindlessly go about your business without ever being fully present in the moment.

Every training session or exercise should have a process-based focus at the front of your mind e.g. even pedalling on the bike

Have a mental checklist specific to every exercise you do and tick it for every rep – Are the muscles you’re trying to train engaged? Is your breathing in time? Is your form good?

If you write your own, then reappraise your training plan – Do you believe in it? Is there a coherent plan ending in your goals? Are there ‘junk miles’ you can cut?

‘We all need to stretch more’ – Jamie Kujawa

Looking back on the past 9 months, I’ve only ever thought to stretch when I’ve been pretty much physically broken. I’m sure I’m not unique in this regard and would normally consider 15 seconds or so on each of the major muscle groups in the leg after a run to be a job well done. Yoga seems to have an uncanny ability to find tightness in parts of your body you’ve probably never even felt before. While in many ways different to triathlon, the thread of learning by challenging yourself is common and the benefits undoubtedly transfer. Leaving a class recently having managed to achieve a forearm handstand (against a wall, easy does it) for the first time, I was really pleased; partially because I conquered something I never thought I could do and also because I hadn’t been shown up (too badly) by the 8 other girls!

A couple of thoughts from a very novice ‘yogi’:

Don’t worry how inflexible you are to start with, persistence will pay off

One reason triathletes often struggle to make significant improvements in their swimming performance is that they consider themselves a runner/cyclist that swims, rather than changing between being a swimmer, cyclist and runner depending on the training session. An example of this is learning to flip turn properly. Many triathletes see this as a waste of time because most races are held in open water. This fails to acknowledge that the hydrodynamic awareness gained by learning this skill can have lead to a dramatic increase in swim speed.

http://www.usms.org – The training section of the US Masters website has plenty of articles and session ideas. Unfortunately the ‘workouts’ page requires you to be a USMS member, however other sections such as ‘stroke technique’ are free and useful.

Cycling

‘Watts’, ‘RPM’, ‘RPE’, ‘BPM’, ‘MPH/KPH.’ What’s most important? How can we use them to execute a faster bike split? Leaving talk of bike componentry aside, becoming a strong cyclist involves more that just Sunday group rides with your mates. Time trialling is the key skill all triathletes competing in non-drafting races will have to master. This involves hard solo training sessions and the resources below will, I hope, give you some session ideas and things to focus on.

http://home.trainingpeaks.com – Further to the well-known training analysis platform used by many coaches/athletes, this website contains a well-written blog on a wide range of training topics. Although not free, Training Peaks also have a wide range of target driven training programs available to purchase.

http://www.cptips.com – While their website layout is slightly basic, Cycling Performance Tips contains tonnes of articles and information relating to all aspects of cycling.

Running

Getting carried away with increasing mileage and speed can be a major pitfall in the progression of any runner. With the help of some of the websites below you could become a better runner without even putting your trainers on.

https://www.youtube.com/user/yogatic – The Ekhart Yoga YouTube account has loads of easy to follow free yoga videos, helping you to stretch out tight muscles. Check out their ‘Yoga for Runners’ videos.

https://iancorless.org – Ian Corless’s ‘Talk Ultra’ podcast, while actually aimed at ultra/mountain runners, contains interesting interviews relevant to anyone that races Ironman or runs off-road. You’ll end up wanting to try races such as the UTMB, Zegama-Aizkorri and the Kima Trophy!

Strength & Conditioning

A stronger triathlete is a faster triathlete. Every athlete should implement gym training as part of his or her training routine. Timing and purpose are vital to ensure positive results.

http://www.ironmacfitness.com – Andy McKenzie is one of the UK’s most respected strength and conditioning coaches. His no-bullshit approach has helped many athletes gain better control of their bodies, avoid injury and maximise their performance. For workout ideas, have a look at the media section of his website, sign up for occasional emails and follow him on Instagram.

http://www.functionalpatterns.com – The Functional Patterns website blog and social media pages contain a wealth of information aimed at safeguarding the body against the impact of modern culture, such as sitting for long periods.

Just when you thought there was one sport you could fall back on if running/cycling ruined you, perhaps think again. While swimming does have a much lower rate of injury than the other triathlon disciplines it can present some problems in its own right.

The particular issue that has been afflicting me recently is elbow pain, specifically medial epicondylitis (aka Golfer’s Elbow). I’ve been swimming regularly and consistently for a number of years now and so when I started to get elbow pain back in January 2016 I was puzzled. The pain itself centred around the bony protrusion on the inside of my left elbow, where a tendinous sheath inserts and from which many of the muscles of the forearm attach. These muscles are commonly involved in flexing and pronating the wrist, like you do during the catch and pull phases of a front crawl stroke.

Now, normally you could put a swimming injury down to either poor technique or a significant change in training load. My technique is by no means perfect but I’m sure such a problem would have developed years ago if that was the root cause, while as I said previously I have not changed my training load significantly. Upon reflection, January 2016 was when I first started ski touring and I think over-gripping my poles as I frantically tried to stay upright while following my friend Zach around the mountains of southwest Montana was probably what first sparked it. Since then my consistent swim training has magnified the problem and not allowed it time to heal.

I would class this injury as major niggle rather than a Mike Tyson knockout and so have managed to continue training for the upcoming season without too much deviation. Below I discuss some of the questions it has raised and things I have tried.

Tedonitis or tendinosis?

‘-itis’ means inflammation, while ‘-osis’ means chronic degeneration as a result of tissue death (no inflammation). While the difference may seem subtle there are implications for treatment. There is now significant research to suggest that the vast majority of tendon related injuries are tedinosis, based upon histological tests indicating markers of tissue death but not inflammation. The difficulty with this is that the term ‘tendonitis’ is now so commonplace that a lot of medical professionals still wrongly use it. A quick Google search of ‘golfers elbow’ brings up a myriad of pages talking about inflammation and the role of NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen and diclofenac in treatment. The reality is that these are not helpful in treating tedinosis, should not be taken long term, and can have harmful effects on athletes if taken during periods of training.

Reassess your swimming

In the first instance, you should get someone to check that the root cause isn’t likely a fault in your technique. If an issue does exist then it’s really helpful for you (the athlete) to be able to see this by getting your coach or a friend to video your stroke from all angles using a waterproof camera. Some key points to consider. There is already so much written about swimming technique but the main pertinent point to look for in your freestyle is the position of your elbow during the catch, pull and recovery phases.

One helpful thing I have learnt is to shake out my forearm and wrist during the recovery phase of each stroke while swimming distance. This promotes blood flow and relaxes the muscles.

For me, the pain associated with medial epicondylitis does not appear to be confined to one particular stroke but it is definitely related to how fast I swim. This means that while I have continued to swim through the injury I have tried to be mindful of the additional strain exerted by sprinting, and so have limited the amount I do.

Support the forearm

The idea here is to reduce the strain on the tendon by applying a counter-force brace just below the injury sight. I’ve been trying the AirCast Pneumatic Armband ($12 on Amazon) recently but have not found it to make much of a difference so far. The key is finding the balance between it being tight enough to have an effect but not so tight that blood flow is restricted.

The other support I have tried is RockTape. There are many different taping methods you can try, just search on YouTube, I haven’t yet found one that is vastly better than any of the others. The advantage of taping is that you can swim while wearing it. I found it to be even less supportive than the brace though, and it does tend to come off quite quickly because of the location.

While I’m not particularly positive about these there’s certainly no harm in trying them.

Stretching, massaging and exercises

Begin with massage and exercises before you start intensively stretching. The overall aim of this is to relax the attaching muscles, strengthen the surrounding muscles, break down scar tissue, promote blood flow and help collagen fibres align. If the injury heals without the collagen fibres aligning then they do not full function under load and can lead to permanent weakness.

Massage:

Use a golf ball, The Stick or just your opposite hand

Start off gently

Work from the elbow towards the wrist

Don’t aggravate the painful area any more

Work out any trigger points

Do little and often

Stretching:

Stretch all the muscles of the forearm

Plenty of videos on YouTube

The aim is to achieve a full, uninhibited and pain free range of motion

Again, do little and often

Exercises:

Focus on strengthening exercises that place the flexor muscles under eccentric load – This stretches the muscles out and promotes collagen alignment

In mid-May 2014 and I was returning to running from a fairly minor injury with unfortunate timing that had forced me to withdraw from the London Marathon. My legs felt strangely fresh and injury free after four weeks off and I launched back into training with gusto. By the end of the month I was running 100km a week and feeling strong. I continued with this mileage until the end of July when I went on a running camp/holiday to the French Alps.

By this time I had entered the famous CCC 100km race at the end of August, starting in Courmayeur (Italy) and ending in Chamonix (France). My plan was to spend the five days in July as course reconnaissance and altitude training so I really want to make it count. Rather than taking it easy to adjust to the altitude and the size of the terrain I pushed very hard on every run, naively following the phrase ‘go big or go home.’

On the third morning when I woke up and put my foot on the floor my heel felt bruised and as if I had trodden on a sharp stone, my calf muscles were also tight from the endless uphills. Before long the soreness had largely subsided and I got on with training for the day. I did a very hard run taking in the Col du Bonhomme, where I was very pleased to unexpectedly be informed by Strava that I’d beaten Kilian Jornet’s time up it!

Again the next morning the pain was back and this pattern continued when I returned home for at least a week before becoming continuous pain when weight bearing. I knew then that I’d missed a chance to listen to my body, take a short break and return without a problem. With the race only weeks away I tried to continue running but it was not a pleasant experience at all. The only mild relief seemed to come from massively overloading the plantar fascia by standing in a doorway with my hands braced against the top and pushing up in a heel raise as hard as I could with the injured leg. I later learnt that instead of stretching it into recovery this was only serving to stress it even more.

The weekend before the CCC I had a weekend long military selection course. I wasn’t too worried about this though as I knew I was more than fit enough to get by. The final morning was a timed solo 1.5-mile run and by this stage the training staff knew that I was a good runner and applied some pressure for me to break their ‘record’ of 07:20. I knew that I was capable of a sub-7 minute time if my foot pain didn’t slow me down so I took off on the run very fast, determined to impress. Within 300m a massive and sudden sharp pain shot through my heel, it was agony. I knew I’d ruptured my plantar fascia. I continued the run as fast as I could with a very strange gait, managing to finish in 07:50 much to my embarrassment. I grimaced through the rest of the day and collapsed on the train home. By this stage my heel had swollen and it was incredibly tender. I knew that my CCC dreams were over and I was gutted.

Later in the week I went to my local GP and physiotherapist who concluded that I simply had plantar fasciitis and to rest from running, which I knew was bullshit. Within three weeks the pain had largely subsided and I started running slowly again but I could feel that my foot was biomechanically very different, with little ‘spring’ in my step. I persevered, thinking that perhaps I just needed time to adapt, but within a week of running I had a lot of localised pain around my third metatarsal. This time I went to see an orthopaedic specialist who, understanding my seriousness about running, referred me for an x-ray and a CT scan. This concluded that I now had a stress fracture of my third metatarsal. I was placed in a ‘Beckham boot’ for 6 weeks, and after some time told I could return to running VERY CAUTIOUSLY. Of course, I took this to mean SMASH IT but never took my weekly mileage beyond 60km, which I thought was cautious enough! By early 2015 I’d started getting pain in the arch of my foot but ignored it as I had big plans for the season to avenge my CCC withdrawal. I ran in The Grizzly in early March, a tough 20 mile multi-terrain race, coming 2nd out of 1,500 people. I was really pleased with this but my foot hurt so much afterwards. I went back to the orthopaedic specialist and was referred for an MRI. The results found that I had indeed ruptured my plantar fascia the previous summer, and that it now appeared my spring ligament and tibialis posterior tendon were damaged too. A HATRICK OF INJURY! With some stern advice that I now had the foot of an 80 year old I finally backed off running.

For summer 2015 I concentrated more on cycling and swimming, which didn’t inflict any pain. I had regular Extracorporeal Shockwave Therapy to attempt to aid the healing of the spring ligament and post tib tendon, and started wearing Formthotics insoles.

Having many months of no running to reflect on what I’d done wrong, I conclude the following:

If I’d taken a more moderate approach in my original return to running I probably never would have started this chain of events

If you go on training holidays, don’t feel you have to cram as much in to them as possible

Listen to your body as soon as it starts complaining, not later!

Your feet are really important, look after them

Keep your calf muscles loose when you start getting plantar fasciitis

Avoid loading the plantar fascia by stretching it too much when in the acute phase of injury

Tendon, ligaments, muscles and fascia do not operate in isolation; injuring one increases the chances of injuring others if not properly managed

Many GP’s and physiotherapists simply are not used to seeing athletes. They simply didn’t believe that I could have ruptured my plantar fascia while ‘just running’

Increasing mileage often doesn’t make you any faster at running, it just injures you more quickly

TRAIN TO RACE, DON’T RACE TO TRAIN – e.g. if your goal was to run a sub 40 minute 10k, work on all the components that will lead to this, don’t just try to smash 10k pb’s for training. (And don’t try and beat Kilian Jornet in training either!)

I’m now back to running a bit but doubt I will ever be able to exceed 50km per week without risk of further problems. My injured foot has a slightly different appearance to the other, with a fallen arch (although not completely collapsed). Right now I’m just happy to run at all and it’s made me enjoy it even more.